consulttest

Form #3 >

Patient's Other Tests

Form #3:

Following the completion of this form (Form #3), your consultation request will be completed. After clicking "Submit query" button on this page, please do the following: in a separate e-mail addressed to consult@webpediatrics.com (or click on "Attachments: other tests" on the bottom of this page) write patient's code in the "Subject" line, in the text space list all tests that are being sent, and by clicking "Attachment(s)" in the e-mail window you can attach and send scanned (or originally digitalized) x-rays files, ultra sound scans, electrocardiograms (ECG), computed tomography (CT) or magnetic resonance imaging (MRI) files of the patient.

Attention: The total size of files that can be sent by e-mail can be limited by your Internet service provider. If you encounter any problems with file transfer, check with your Internet service provider.

Acceptable file formats for images are: .JPEG, .JPG, Windows Metafiles, .BMP, .GIF, and Adobe .psd, .ai and .TIFF. Video files of procedures should be sent in any standard video/movie format (.MPEG, .AVI, etc.)

Fields marked with (*) must be filled out.

Code (NN-00000000)*
e-mail*

List in chronological order written reports of x-ray tests performed on the patient for current illness. Enclose date of the test, the name of the test, and name of the institution where the test was done.	1. 2. 3. 4.
List in chronological order reports of ultrasound tests done on this patient as a part of care for the current illness.	1. 2.
List dates and results (written) of CT (computed tomography) tests that have been done on the patient. Please enclose the name of the institution where test was done, and the exact name of the test (e.g. with or without contrast, etc.)	CT
List datees and results (written) of MRI (magnetic resonance) tests done on the patient regarding the current illness. Please enclose the name of the institution where test was done, and the exact name of the test.	MRI
List dates, results and descriptions of any other tests performed on the patient as a part of medical care for current illness.	OT

Attachment: other tests

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